Surprisingly, there is little attention in the media - since Friday, there have only been a handful of articles relating to the updated recommendations. The few published are almost all identical in wording and based on the press release issued on Friday by the ADA.

These two documents now stand as the "gold standard" for physicians and healthcare providers to determine the course of treatment for their patients at risk for or diagnosed with diabetes. While both documents claim an evidence-based approach in their creation, they rely heavily on previous reviews and time-honored dogma.

They also quietly tell us something that should make physicians and healthcare providers, and the general public question the trust bestowed upon the ADA as the leading, authoritative organization to find a cure, and more importantly be responsible to us for communicating the best science available. After decades of research time, millions of dollars, and billions of manhours - the ADA has not only failed find a solution to prevent diabetes, it is also currently unable to curtail the epidemic of diabetes.

While admitting the "current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes," they continue down the very same path that leads to slow, insidious progression of the disease.

One example of this from the new MNT guidelines should suffice to highlight the insanity of it all:

"Sucrose can be substituted for other carbohydrate sources in the meal plan or, if added to the meal plan, adequately covered with insulin or another glucose-lowering medication."

In other words, it's fine to make your condition worse as long as you take and adjust your drugs.

I could spend hours picking apart the various recommendations that are destructive to the long-term health of those at risk for or diagnosed with diabetes, and then pull dozens of credible studies that found improvement with an alternative approach. I simply do not have that kind of time these days.

I have however, previously written a number of articles that sum up much of the research data available that has continued to be ignored:

What we have now, with these two new position statements, is clearly an effort to reduce the options made available to those at risk for or diagnosed with diabetes.

Rather than taking the time - and let me be clear, it is a time consuming process - to actually review the reams of data available that specifically found statistically significant improvements in those subjects with insulin resistance and impaired glucose tolerance or diabetes following a carbohydrate restricted diet, the ADA has firmly placed its stake in a failed dietary approach and simply added a pharmacuetical intervention at diagnosis in the hope that the drugs may at least slow progression if prescribed earlier.

That's not all though.

The ADA isn't simply standing its ground, as shaky as it is, here.

They're not just ignoring evidence or dismissing data anymore - they've gone a step further to issue a blanket condemnation of a scientifically supported dietary intervention and crafted a message to healthcare providers and the public that tells them, in no uncertain terms, they can't do it anyway, so don't even bother to consider it.

In the real world, that's called hubris - only pure arrogance leads an organization the size of the ADA to declare "we know what's best for you," while at the same time admitting it isn't able to do more than stay the course and add drugs earlier.

I've reached the point where even my hope that the ADA will evaluate the evidence, take the valuable hard date available, and issue even a cautious guideline to carbohydrate restriction, has evaporated.

With these two new statements, the ADA has shown its worth in our future - a future which looks grim if nothing changes - the ADA is now irrelevant.

It is up to those who are truly committed to the use of evidence-based medicine to collaborate, unite and review the evidence to create a comprehensive guideline for use by healthcare providers. Those currently in practice and treating those at risk for or diagnosed with diabetes, and those investigating its potential, must take on the task since it's clear the ADA is not going to do it.

It's also time for those who are at risk for or diganoised with diabetes to step up and be heard - write letters to the editor of your local newspaper, the national newspapers and your congressmen. Tell them enough is enough - we want a all options, based on credible studies, provided to physicians, healthcare providers and the public!

Monday, August 28, 2006

Last week Dr. Mike Eades commented on the FDA approval of spraying viruses on our food in An opportunity for the law of unintended consequences to rear its head. I'm personally not fond of the idea food companies are going to be spraying viruses on our food in an effort to eliminate bacteria. One more reason, in my mind, to skip the processed foods and stick with real, whole food.

One of my all-time favorite nutritionists, Dr. Jonny Bowden, has a collection that anyone trying to lose weight should consider adding to their library - The Power to Change is a series of CD's designed to motivate, motivate, motivate. There are three separate collections - Change your Body, Change your Life; 23 Ways to Improve your Life; and 9 Essential Steps to Weight Loss. Each may be purchased separately or you can save some money when you purchase all three. For the record, I receive absolutely NO compensation for linking to these great CD's!

The great thing about a low-carb diet is that once you get into the groove, it gets easier with time. After three weeks, I'm in my groove and decision making, about what to eat, is best described as "auto-pilot" - I know what to eat and meals come together with little effort or planning. The only adjustment made in week two was the inclusion of more carbohydrate, specifically from nuts, seeds and some fruits. I continued this into week three and averaged 30-40g of carbohydrate each day. With a full range of options, this simply doesn't feel like a diet.

So, how did I do in week three?

In week one and two I lost an impressive amount of weight - 15-pounds; more than I anticipated. Starting week three the scale actually bumped up a couple of pounds, then settled for a few days before starting a downward trend again. I awoke this morning with an additional 1-pound weight loss, to bring my three week total to 16-pounds. Yeah!

Now some may be thinking, that's it? Yup - that's it...and a pound in week three means, without giving it much thought, I maintained a calorie deficit without counting my calories. The scale going up-steady-down again in the week tells me that my glycogen stores stabilized this week also.

As I start week four, I'll gradually increase carbohydrate once again - this week targeting a minimum of 40g (net, deducting only fiber) carbohydrate each day and consuming up to 60g net. At the same time, I'll make just one change - I'll swap my morning heavy cream out and instead use half & half in my coffee.

This one minor change saves me 60-calories - enough to add more foods with slightly higher carbohydrate content. Basically this exchange buys me 15g of carbohydrate to use throughout the day, which I'll enjoy with some more non-starchy vegetables, fruit and nuts!

With just four more pounds to lose, I'll continue at this level of carbohydrate throughout the rest of my weight loss. These days I am in a bit of a time crunch, so I won't post menus each day, but will post a few during the week to provide examples of what you can eat at this level of carbohydrate!

Friday, August 25, 2006

Monday I featured an online segment of dLife TV that highlighted the two sides of the debate about which type of dietary recommendation someone diagnosed with type II diabetes should receive. On one side we have those who feel recommending a low-carb diet, and thus advising a radical dietary modification, is an exercise in futility - either because the patient cannot or will not limit carbohydrate to control their disease; on the other side we have researchers publishing study after study with statistically significant improvements and physicians and healthcare professionals already making the recommendation to use a low-carb diet, who insist that when patients "see the pay off they stick with it."

In the comments, Kevin Dill, who follows a low-carb diet himself, asked a good question:

I guess my only question is which definition of a low carb diet are we going to use?? While Dr Atkins has provided the most popluar version, is it any better than Protein Power, South Beach, the Zone, or any of the other of myriad interpretations of low carb when it comes to controlling blood sugar?. IS Ketosis necessary? or is simply reducing the carbs below a certain level, (what ever that may be), sufficient? IF low carb is the one true answer, then why has DEAN ORNISH also been successful?? The real culprit is not just the carbs, its the constant state of over consumption, compounded by a sedentary lifestyle. While I agree that a low/reduced/controlled carb diet should be offered as an option, its only opening up a whole new can of worms. If the low carb community can't agree amongst itself which plan is "right", how would you expect people who aren't overly fond of the idea of reduced carbs to fair? But then again, they may do a better job with it as they do not have the emotional attachment that so many low carbers have to their chosen plan.

First some clarification - again - low-carb may not be the "one true answer" for every person diagnosed with type II diabetes. I've stated this previously and most recently on August 18th, "I don't think that only a low-carb diet should be recommended, nor do I think that initiating a drug at diagnosis is necessarily a bad idea."

My view is simply this - a low-carb diet has sufficient, credible and compelling data published at this point. Enough that it should be reviewed, an appropriate approach to low-carb eating defined, and then it offered as an option to anyone diagnosed with type II diabetes if they prefer to try to control their blood sugars with this alternative dietary approach. What we lack is a good, working definition of a low-carb (or controlled-carb, or carbohydrate restricted) diet and a clinical practice guideline. As pointed out above, which plan out there should be advocated as an appropriate diet for those diagnosed with type II diabetes?

From my perspective, the question shouldn't be "which popular diet to recommend," but "what does the data tell us is a level of carbohydrate that results in statistically significant improvement?"

The only approach here, in my mind, is a strict evidence-based approach which demands we set aside opinions, beliefs, anecdotes and assumptions and carefully review the hard data as the basis of our first step to definition for clinical application.

As it is now, we have two camps in the diet debate: those who advocate the carb-rich diet, with 45-55% of calories from carbohydrate, espoused by the leading organizations and government, countered by an assortment of various approaches to carbohydrate restriction with limited definition for practical use with patients. The carbohydrate intake of the various published carbohydrate restricted diets out there is all over the place - some recommending as little as 20g net carbohydrate per day to start and maxing out at about 100g net a day, some more moderate levels ranging from 72g to 150g a day, and others allowing up to 40% of calories from carbohydrate.

The current recommendations are available almost everywhere you turn - in print, the internet & media and hand-outs in the doctors office; the carbohydrate restricted diets are often designed by trial-and-error by the patient advised to reduce carbohydrate with little practical advice about how to do that. While some physicians have created patient hand-outs, many will not due to a fear of what may happen for making a recommendation contrary to the established guidelines.

We know the diet promoted these days may slow progression in some, but has yet to halt progression or reverse the condition over the long-term; we know the low-carb diet - in dietary trials - reverses the condition in some, returning blood sugars, cholesterol, insulin, weight and blood pressure to normal levels and also reduces or eliminates the need for medication; but, in an on-your-own approach, undertaken without clinical guidelines based on evidence, carbohydrate restriction may or may not have the same beneficial effect.

Without a practical, clinical guideline, physicians and other healthcare professionals advising a low-carb diet are left to design what they think a carbohydrate restricted diet is, which may or may not translate to the actual type of diet designed in clinical trials that resulted in statistically significant improvements; and the oft-vague advice to reduce carbohydrate without specifics leaves too much room for error by the patient due to a lack of evidence-based information to use in their daily menu planning.If we maintain the status quo, that is each side in the debate remaining in their comfort zone surrounded by like-minded folks, unwilling to engage with the other, nothing will change. I've watched as opportunity after opportunity was lost the last four years to find common ground and agreement, all in the name of each side insisting they know better than the other, believing the other is too entrenched in their beliefs to even sit and review the evidence.

So while this status-quo approach has maintained each view within its own cocoon of knowledge, it's established a precedent to dismiss, ignore and ridicule the other with little more than a belief that one side is right and one side is wrong.

If only it were that simple. If only things in this world were always black and white.

The only way to hammer out a definition and clinical guideline is to engage both sides and insist each side bring to the table their knowledge, understanding and evidence, review the evidence from the other side, and work together to improve the dietary recommendations for those diagnosed with type II diabetes.

This is no longer a matter of one side being right and the other wrong. We are in the middle of an alarming epidemic in the United States and can no longer afford to have either side sit on their laurels, basking in the belief they're right, damn the torpedoes.

Evidence-based medicine demands we sit together, review the evidence and use that data to establish truly evidence based guidelines. It demands we take the findings and use them not only because we've taken the time and resources to search for greater understanding, but because the data is what it is and not simply an opinion or belief.

Evidence-based medicine demands we do this even when we do not like or agree with the weight of the evidence available.

At the present, all of the popular, published diets work, yet each has a particular spin to differentiate it from the others. Some are very low-carbohydrate initially and ramp carbohydrate back up to low- to-moderate levels, yet still strictly reduced levels over time; some reduce carbohydrate significantly and maintain that low level of carbohydrate for the long-term ; and some simply reduce carbohydrate to a moderate level and ask those following to maintain that reduced, moderate level over time.

Recently a "next generation" of carbohydrate restricted approaches has cropped up - glycemic index and glycemic load; banning the white stuff; consuming whole foods only; or limiting sugar in the diet. While these are not promoted as "low-carb," they're based on the functional understanding of carbohydrate and sugar in the metabolism.

Each of the above popular diet plans is designed mostly for those seeking to lose and maintain their weight. With few exceptions, they're not specifically designed for those actively seeking to control their diabetes. While a number of these plans work well for those with type II diabetes, a person with type II diabetes is often left with too little information to make a decision from based on their current health status.

A clinical guideline, developed from the available data, in an evidence-based approach would enable a physician or healthcare professional to work with their patient to make a good decision about which dietary level of carbohydrate to use as a means of glycemic control.

The longer the established dogma remains and the longer those advancing carbohydrate restriction continue to differentiate and try to gain a some kind of recognition from the establishment by crafting "politically correct" diets, the more consumers will be confused and the less likely they'll be to get it right on their own or with their physician.

The time is now to take the leap from talking the talk of evidence-based medicine, to walking the walk and practicing what we preach - an actual review the data and then following the principle of evidence-based medicine to establish an evidence-based clinical guideline for dietary recommendations for those diagnosed with type II diabetes.

It will be a start, it will enable those diagnosed to decide if such a dietary approach is something they're willing to try, it will open the door to new avenues of research and it will potentially allow us to reverse the trend of increasing incidence of diabetes that, if we do nothing, promises to destroy our future.

The question really is, are the powers that be up to the task of a truly evidence-based approach? If they are, we can look forward to an evidence-based clinical guideline; if not, don't expect much to change anytime soon.

In a backgrounder released in March, the provincial health ministry announced the following ActNow BC targets for 2010: "Increase the percentage of the B.C. population that is physically active by 20 per cent; increase the percentage of B.C. adults who eat at least five servings of fruits and vegetables daily by 20 per cent; and reduce the percentage of B.C. adults who are overweight or obese by 20 per cent."

Laudable as these goals are, they were remarkable in their ambition, as no other jurisdiction in the world has been able to accomplish such improvements in a general population.

As someone familiar with the research on obesity and the associated chronic diseases, I assumed that there must be a new and innovative secret weapon up the government's sleeve to make it possible to reach such ambitious targets in so short a time.

Unfortunately, it now appears otherwise. All need not be lost, however.

Even with a mere three years left, it would still be possible to make real gains if people were prepared to abandon the current failed dietary dogma and objectively consider an emerging body of evidence that points us in a completely different direction.

There is credible scientific evidence that a diet high in carbohydrates, like the one we are encouraged to eat by all manner of authoritative sources, is actually contributing to overweight, obesity and the resulting epidemics of chronic diseases. On the flip side, there are numerous studies that demonstrate that low-carbohydrate diets are effective at reversing these conditions.

First: For the vast majority of the past two million years, our forebears ate a low-carb diet. The agricultural, grain-based diet we eat today emerged a short 10,000 years ago, a blink of the eye in terms of evolutionary time.

Second: Mainstream belief systems resist change, even in the face of compelling evidence. Consider that less than 200 years ago, the medical establishment firmly believed that blood-letting was the best treatment for fever.

When an early study showed that blood-letting was not effective, the establishment responded that blood-letting should start earlier and be done more vigorously.

This is not unlike the current response to the colossal failure to reverse the epidemics of obesity and chronic disease. We are told that the cure is known, our only failure is that we haven't tried hard enough to deliver it.

Unless we are prepared to shake off this dogmatic approach and consider new, credible evidence that points us in a more promising direction, I fear we are doomed to fail in the 2010 quest and, more importantly, in the larger effort to mitigate the human and societal costs of these preventable epidemics.

Dr. Jay Wortman is with the department of health care and epidemiology at the University of British Columbia.

Wednesday, August 23, 2006

With the summer bounty of squash, it's often difficult to eat it all before it spoils. In addition to sauteeing it with butter and herbs, I also make it into soup that can be frozen for consumption later in the year.

In a large pot simmer cut squash in chicken broth, butter, chopped onion, whole onion, garlic and spices until squash is cooked soft and tender. Remove whole onion and discard. Puree squash and broth mix together and add heavy cream, add more chicken broth or water to desired consistency for a creamy soup. Season with salt & pepper to taste. Serve hot, topped with a dallop of sour cream.

If freezing, do not include sour cream! Add it once it's thawed and re-heated.

I've posted menus over the last two weeks to provide some insight into how I eat when following a low-carb diet. If you've been reading them each day, you might have noticed they're consistently similar each day. This week, with no increase in carbohydrate, my menu is going to look very similar to last week's, and with time limited this next week, I won't be posting menus each day since 14-days worth of menus are available as example!

Tuesday, August 22, 2006

As we're all aware, type II diabetes is a progressive, degenerative disease, that takes its toll over the long-term; leading to blindness, amputation of limbs, kidney failure, cardiovascular disease and more. Management of the disease is time consuming and often painful, with daily blood sugar monitoring and oral medication; and as the disease progresses, daily insulin injections.

Recently an American Diabetes Association consensus statement acknowledged the lifestyle intervention that includes a carbohydrate-rich diet, recommended for decades by the organization to those diagnoised with type II diabetes, has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes.

In the statement, a new algorithm of management, starting at diagnosis, includes the same failed dietary intervention, now with the addition of pharmaceuticals.

As I've previously written, on the one hand we have the ADA acknowledging its dietary advice is worthless; on the other we have the ADA refusing to adopt, even cautiously, a dietary recommendation shown to improve blood sugars, insulin and HbA1C, and reduce risk markers for diabetic complications - a low-carb diet.

It seems part of the disconnect between the data in studies and the recommendations made by experts in the field is one of convenience. And no, in this instance I'm not talking about conveniently ignoring evidence or the inconvenience of data. In this instance, I'm talking about inconveniencing a patient diagnoised with type II diabetes.

For some reason, it seems, we have no problem inconveniencing a patient with the daily tasks of managing their disease. Inconvenience the patient with monitoring their blood sugars daily - just don't take away their bread; inconvenience the patient with remembering to take their medication each day - just don't take away their potatoes; inconvenience the patient with their daily insulin injections - just don't take away their pasta.

Do we even consider such insanity when someone has alcoholism? Seriously, do we consider anything but abstinence in an effort not to inconvenience the alcoholic?

Do we consider such nonsense when someone is diagnoised with celiac disease? Seriously, do we dream up ways a person with celiac disease can eat wheat so they don't have to give it up in their diet?

Absolutely not!

Why then are we even having a debate about the recommended dietary intervention for those daignosed with type II diabetes?

A low-carb diet has been shown, in study after study, to improve blood sugars, insulin levels and HbA1C, often to within the normal range of a non-diabetic; improve risk markers for complications associated with type II diabetes; and even eliminate the need for medication. Diet alone.

The ADA position, articulated by ADA spokesman Nathaniel G. Clark in June of this year, "We want to promote a diet that people can live with long-term. People who go on very low carbohydrate diets generally aren't able to stick with them for long periods of time," is based on the assumption that a patient won't want to live with giving up potatoes, rice, pasta, bread, cake, cookies or sweets; that such a diet is too restrictive and impractical in the life of someone already on the road to progressive deterioration due to their disease.

The ADA is not alone in this position.

Many prominent diabetes experts are of the opinion that expecting a person diagnoised with diabetes to make a radical change to their diet is unrealistic and potentially damaging to their self-confidence.

What?

Yes, it's true.

It seems Dr. Howard Wolpert, MD believes that educating a patient about the potential of a low-carb diet to reverse HbA1c to non-diabetic levels is an "over idealized" goal and just too hard for a patient to follow. He doesn't let the inconvenient fact that Dr. Richard K. Bernstein, MD has done just that with thousands of patients over decades of practicing medicine assault his sensibility - patients want their pasta and without it, they're doomed to low self-esteem.

As Dr. Bernstein said in the recent debate, available for viewing on dLife, after starting a low-carb diet, "when patients see the pay off they stick with it."

The pay-off is improvement; often with reduction or elimination of medication.

Take a moment and see the dLife segment highlighting the debate of what good diabetes control really is.

The finding is sobering - in hospital mortality (death) is twice as likely in those with high blood sugars compared with those with normal blood sugars. At a baseline normal blood sugar range upon admission for heart failure, each 18mg/dL increase in blood glucose increased the risk of in-hospital death by 31%.

In addition, in those that survived initally in the hospital and were released, the risk of death in the first sixty days following heart failure was also higher in those who had elevated blood sugar at admission for heart failure - an increased risk of 12%. After six months and one-year, there was no risk difference between those non-diabetics with normal or elevated blood sugars at admission.

The researchers concluded that elevated blood sugars in non-diabetic patients is an independent predictor of in-hospital and 60-day mortality.

Our finding calls attention to a new prognostic marker that could be used for early risk stratification and management of patients with HF at hospital admission. It is possible that better glucose control may improve prognosis in hyperglycemic patients with HF, as demonstrated in acute myocardial infarction and critically ill patients.Further research is needed to determine whether hyperglycemia is a marker or cause of adverse outcome and whether immediate, tight glycemic control would confer benefit and improve survival in these high-risk patients.

Week two of following a low-carb diet again went well. Once you're past the initial few days of getting used to less carbohydrate eating is much simpler - you eat your vegetables and salads along with whatever meats, poultry, fish or game you want. And, if you stick with it, you lose weight.

In week one, I lost an incredible ten pounds - much more than I expected, but still it was mostly water weight. As the scale continued downward this week, I debated whether to include my weight loss this week or not because it was another banner week for losing pounds - as of this morning, I've lost another five, down a total of fifteen pounds. I'm not exactly suffering the fate of the concept of the "one golden shot" as some insist happens the second or third time around.

While I have heard of, read about and received emails asking about the "one golden shot," I've never put the theory to the test. For me, it seems, it doesn't apply. Thankfully.

For others I know, it does and is a painful reminder that if you abandon a controlled-carb diet, getting back on track and back to maintenance weight can be difficult and can take longer than the first time you follow a low-carb diet. The thing to keep in mind is that it's better to stick with controlled-carb than to go back to eating as you did prior to low-carb and risk the "one golden shot" applies to you.

But, even if you are just getting back on track and find the weight loss slower the second time around, it's worth the wait to lose the weight since eating a controlled-carb diet is better for you and your health. If you are affected by the "one golden shot" do not dispair, the second or third time around may be slower for weight loss, but you will still lose the weight if you stay on track and eat well.

If re-starting is harder than you remember, there are a number of online forums where you can find support from others who are following a low-carb or controlled-carb diet:

"On the one hand I agree with your position about the need to reduce carbs for diabetics. On the other hand,...I know from first hand experience in dealing with memebers of my own family that trying to get some people to change thier dietary paterns is an exercise in futility and they would be better off if they had just started the meds early."

In my email, I've received similar comments:

"Eating a low-carb diet isn't always easy or within the budget of many people. It looks easy on paper, but in practice it is harder than it sounds, especially with busy lifestyles and an environment where "the bad foods" are everywhere. If you don't consider that a lot of people with diabetes won't change their diet, the recommendation to follow a low-carb diet is going to be as useful as the recommendation to follow a low-fat diet - it will do nothing to change things if it's not followed."

"I've seen so many people around me diagnoised with type II diabetes, it's scary! For so many it is just easier to pop a pill and eat what you want and not have to think about what you're doing to your body every time you eat something you shouldn't. I don't agree with the first step being a diet and drugs combination, but honestly, I'm not sure that many people would follow a low-carb diet since it is more expensive and eliminates so many things people are used to eating."

"Too many people believe they have to have a bucketload of carbs to be healthy, diabetes or not, and when everyone is saying you need carbs it's hard to believe that reducing them is going to be good. I think most people know what they're eating isn't good for them, but they do it anyway. Expecting them to follow a low-carb diet is like expecting a pig to fly because you tape paper wings to it."

"Diabetes is one scary disease and even when you're diagnoised, you think you can still keep doing what you've been doing and let modern medicine take care of keeping you alive and healthy. You think this because it's hard to accept what you're eating actually might be the reason you now have diabetes. It's easier to accept your body malfunctioned and you now have this disease than to think you might be responsible for your body getting diseased. Recommending a low-carb diet is dangerous ground for the ADA. If they take that direction, it implies the diet advice we're all getting is wrong and might be causing diseases like diabetes. It also tells patients in no uncertain terms their eating habits are the cause of their disease. So instead of going down that path, it's easier to avoid the whole mess and start drugs early to slow down the inevitable that is going to happen if the diet isn't changed. Telling people to change their diet is hard, most don't want to, it's just easier to add something (drugs) if you can keep your old habits and not make changes that aren't easy."

Eye-opening comments!

So, first let me say that I don't think that only a low-carb diet should be recommended, nor do I think that initiating a drug at diagnosis is necessarily a bad idea.

The position of the ADA, concerning low-carb diets, was previously that there was no evidence of any benefit and only potential harm; in June that position suddenly changed when data was published finding statistically significant improvements, below target HbA1C levels and reduction and/or elimination of diabetes medications after following a truly low-carb diet for 22-months. The study was in addition to the dozens already in the literature that found benefit and improvement in those with diabetes; this one though was longer though and more difficult to dismiss.

I'll be the first to acknowledge starting and maintaining a carbohydrate restricted diet can be difficult. We live in a world that seems to revolve around carbohydrate foods - bread, potatoes, pasta, rice, corn - it's difficult to imagine a meal not including one or more of the above; and oftentimes difficult to imagine a day without something sweet.

Part of the problem, as I see it, is perspective; the other presentation.

We've been told for many years, and now firmly believe, that a healthy diet revolves around carbohydrate; and without the majority of calories provided by foods rich with carbohydrate a diet is somehow lacking and unbalanced for the long-term for essential nutrients, taste and palatability.

It's difficult for many to adopt a totally alien approach to eating - let's not kid ourselves, in the world we live, a low-carb diet is totally alien. Adding to the difficulty is the message that a low-carb diet is deficient, unhealthy, unbalanced, untenable, dangerous and a just a fad that is best ignored.

But such sentiments betray the evidence that shows statistically significant improvements in those who adopt and maintain a truly low-carbohydrate diet.

Much of the difficulty today is not so much the diet itself is difficult, it's that the message of fear and intimidation is so loud from the powers that be - they admit the evidence is there, but cannot bring themselves to follow through with an evidence-based appraoch and recommend it as an option, even cautiously.

I'm not insisting on a ringing endorsement here - what I want to see, and belive is a scientifically supported, evidence-based approach, is to present a carbohydrate restricted diet as an option to any individual diagnoised with pre-diabetes or type II diabetes.

It is true that not everyone is going to want to or be able to modify their diet, but for those who want to try and can, restricting carbohydrate may mean a life free from pharmaceuticals for years and every patient deserves to know the option is there and the evidence to-date is compelling.

It should be the patient's choice if they want to try the scientifically supported carbohydrate-resticted diet or follow the new algorithm of lifestyle intervention with medication.

At the moment, no choice exists while at least two options are supported by the evidence - the low-carb diet or the new algorithm.

Instead of providing healthcare professionals and patients with both options, they're being told not to bother with carbohydrate restriction because they can't do it anyway.

Rather than even cautiously communicate to patients that a potentially powerful dietary intervention may be an option they wish to weigh for risk and benefit, the ADA specifically cautions against a low-carb diet to both professionals in the healthcare community and patients.

In this instance, the data is there yet dismissed by those who know better and are tasked with the responsibility to objectively evaluate and review the evidence; they're able to admit the current-day management of diabetes has failed, yet unable to grasp why it has failed.

They're able to admit the data shows following a low-carb diet can result in improvements, yet are unable to bring themselves to even cautiously suggest it be weighed as an option, as a first-line non-pharmaceutical approach for those who prefer to exhaust options before starting a life-long regiment of drugs.

As I said earlier - perspective and presentation are at the heart of why the science is being ignored in favor of opinion.

Perspective here is the ADA holds that while the data from low-carb studies is compelling, no one wants to follow a low-carb diet. Throw in a few contextually inaccurate scare tactics along the way and the ADA has abandon evidence-based medicine and now holds their own opinions and beliefs higher than the data.

Repeat the message often enough, and the healthcare professionals, who would jump at the opportunity to offer the option of a low-carb diet to their patients who prefer a "diet-only" approach, are left with too little science and data to effectively use such an option in their practice.

Repeat the message often enough, and even those patients who would jump at the chance to make dietary changes to avoid taking medications are left with the impression that a low-carb diet isn't worth a second look due to the presentation of information they hear.

I understand the ADA position, that because the current-day management has failed, a more intense approach may slow the insidious progression of type II diabetes if implemented early.

I find it intolerable, however, that the ADA will not at least cautiously present the evidence that clearly finds when a low-carbohydrate diet is adopted and maintained, statistically significant improvements are realized in those subjects who comply with the dietary protocol.

We know and they know the current dietary recommendations are not a long-term benefit to those diagnoised with diabetes. We also know that the emerging data - both short and now long-term - from low-carbohydrate trials is compelling and supports it as an option. I can even live with a cautious option - but the continued dismissal of relevant data is not only irresponsible, but outright negligence!

The belief that no one wants to follow such a diet, or that few can in the long-term, is nothing more than the ADA deciding for the patient what course of management they will be offered and more specifically, the ADA abandoning evidence-based medicine and digging their heels into the muck of dogma and opinion.

Personally, if every person diagnoised with type II diabetes decided they prefer the pharamaceuticals rather than the diet, that's fine with me.

But, shouldn't it be up to the the patient to make that decision and not the ADA?

The statement is said to be based on evidence from well-controlled trials and the expert opinions of diabetes specialists. At its heart, the document stresses the importance of prompt diagnosis of type 2 diabetes and achivement of HbA1c level as close to the nondiabetic range as possible [less than 6%] or, at a minimum, to 7% or less.

"Our consensus is that an A1C of 7% should serve as a call to action to initiate or change therapy with the goal of achieving an A1C level as close to the nondiabetic range as possible or, at a minimum, decreasing the A1C to less than 7%. We are mindful that this goal is not appropriate or practical for some patients, and clinical judgment, based on the potential benefits and risks of a more intensified regimen, needs to be applied for every patient. Factors such as life expectancy and risk for hypoglycemia need to be considered for every patient before intensifying therapeutic regimens."

Later in the statement, it's abundantly clear that diabetes researchers and experts know that the dietary intervention recommended does not work for the long-term. Rather than question the dietary recommendations, or explore emerging data supportive of dietary interventions that are different from the recommendations, the statement instead concludes that "the limited long-term success of lifestyle programs to maintain glycemic goals in patients with type 2 diabetes suggests that a large majority of patients will require the addition of medications over the course of their diabetes."

The final sentence in the section discussing medications, which followed the section on lifestyle intervention, sets the stage for what is to come, "addition of medications is the rule, not the exception, if treatment goals are to be met over time."

The section discussing How to Initiate Diabetes Therapy and Advance Intervention is eye-opening:

The patient is the key player in the diabetes care team and should be trained and empowered to prevent and treat hypoglycemia, as well as to adjust medications with the guidance of health care providers to achieve glycemic goals. Many patients may be managed effectively with monotherapy; however, the progressive nature of the disease will require the use of combination therapy in many, if not most, patients over time to achieve and maintain glycemia in the target range.

And, with the stage set, we find the algorithm is predictable: diet & medication, then add insulin.

Oh, you thought it would be lifestyle intervention to see how effective that is?

Well, not exactly.

Step 1: lifestyle intervention and metformin

[O]ur consensus is that metformin therapy should be initiated concurrent with lifestyle intervention at diagnosis. Metformin is recommended as the initial pharmacologic therapy, in the absence of specific contraindications, for its effect on glycemia, absence of weight gain or hypoglycemia, generally low level of side effects, high level of acceptance, and relatively low cost. Metformin treatment should be titrated to its maximally effective dose over 1–2 months, as tolerated. Rapid addition of other glucose-lowering medications should be considered in the setting of persistent symptomatic hyperglycemia.

Step 2: additional medications

If lifestyle intervention and maximal tolerated dose of metformin fail to achieve or sustain glycemic goals, another medication should be added within 2–3 months of the initiation of therapy or at any time when A1C goal is not achieved. There was no strong consensus regarding the second medication added after metformin other than to choose among insulin, a sulfonylurea, or a TZD. As discussed above, the A1C level will determine in part which agent is selected next, with consideration given to the more effective glycemia-lowering agent, insulin, for patients with A1C greater than 8.5% or with symptoms secondary to hyperglycemia. Insulin can be initiated with a basal (intermediate- or long-acting) insulin.

Step 3: further adjustments

If lifestyle, metformin, and a second medication do not result in goal glycemia, the next step should be to start, or intensify, insulin therapy.

The authors concede in the conclusion, "We now understand that much of the morbidity associated with long-term complications can be substantially reduced with interventions that achieve glucose levels close to the nondiabetic range. Although new classes of medications, and numerous combinations, have been demonstrated to lower glycemia, current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes."

I don't know about you, but the admission that the dietary & lifestyle intervention promoted by the ADA doesn't work should be a wake-up call to evaluate the data on various dietary interventions, rather than be used as a reason to throw our hands up and think throwing pharmaceuticals at the problem is all we can do to solve the problem.

The "problem," quite frankly, is the diet recommended - it is the exact opposite of a dietary approach necessary to reduce blood sugars effectively over the long-term. It sets the stage for continued, progressive deterioration because it does not address the underlying cause of the metabolic distrubances that, in time, lead to type II diabetes.

Until the underlying cause of the progressive deterioration experienced by those with type II diabetes is addressed, no amount of medication is going to stop the continued progression of the disorder. Those with type II diabetes, in the long-term, even with this new algorithm, can only look forward to a continued, progressively worse HbA1C, blood sugar, cholesterol, blood pressure, adiposity, and the resultant complications to their eyes, nerves, kidneys and cardiovascular system.

Because, until the insulin resistance, fueled by hyperinsulinemia, is addressed, no amount of pharmaceutical intervention is going to reverse or stop the damage occuring from within. Granted, it will probably slow it down, but it's not going to stop the damage that continues within the body while in a state of metabolic chaos. The only way to do that is to return the metabolism to a state of balance.

In a hyperinsulin state, balance can only be achieved when demand for insulin is reduced; and reduced demand for insulin can only happen when blood sugars are lowered and stabilized over a period of time.

As the statement makes clear, we can do that with drugs. We can force the pancreas to secrete more insulin to lower blood sugars; we can decrease hepatic glucose output and lower fasting glycemia; we can reduce the rate of digestion of polysaccharides in the proximal small intestine, primarily lowering postprandial glucose levels; we can increase the sensitivity of muscle, fat, and liver to endogenous and exogenous insulin; and when all that fails, we can add insulin, which can "decrease any level of elevated A1C to, or close to, the therapeutic goal."

Or we can address the underlying hyperinsulinemia and reach targets with lifestyle intervention alone. The experts who penned this consensus statement believe it cannot be done with a lifestyle intervention alone.

Remember, early in the statement, "our consensus is that metformin therapy should be initiated concurrent with lifestyle intervention at diagnosis."

That's because, to be repetitive here, the ADA dietary recommendations for those with type II diabetes is worthless as a first line defense for anyone diagnoised with type II diabetes. They know it.

They also know there are hundreds of studies published and readily available that show strong support for a dietary intervention they will not consider - a low-carb diet.

In every study available, where subjects complied with a truly low-carb diet, the results cannot be ignored...statistically significant improvements in every risk marker for type II diabetes:

Instead of considering this alternative, the ADA and the EASD consensus is to continue recommending a dietary approach understood as worthless and now add pharmaceutical intervention at diagnoisis since they know the diet alone isn't going to do squat for the long-term.

If you were paying attention earlier, this new line of treatment comes complete with recommendations to achieve compliance in patients, who will be "trained," and whose treatment will be "managed" and "implemented by health care professionals with appropriate training, usually registered dietitians with training in behavioral modification."

All because "[t]he authors recognize that for most individuals with type 2 diabetes, lifestyle interventions fail to achieve or maintain metabolic goals."

Sadly, the only dietary approach considered as part of the failed "lifestyle intervention" is the one promoted by the ADA - a diet rich with carbohydrate that only makes things worse for those with type II diabetes.

And, [yes, I'm repeating myself again] instead of challenging the notion that diabetics "need" carbohydrate, and lots of carbohydrate, we're talking 55% of energy each day - the "experts" continue down the road to the inevitable, next logical step when they won't acknowledge the underlying problems caused by the dietary recommendations, and come to the only thing left - let's add drugs earlier in the management of type II diabetes.

Based on the evidence they chose to review and cite in the paper, their recommendations and conclusions are understandable. The biggest problem though, is they failed to consider or acknowledge any evidence or data outside the accepted dogma that those with type II diabtes need a diet where the majority of calories each day come from carbohydrate.

Don't even think to tell me there isn't any data supporting carbohydrate restriction; or try to concede it's there but too short term to even consider; or that diets that reduce carbohydrate lead to other complications - not a valid arguement when the statistically significant improvements thus far are found in the very risk markers that improvement is called "reduction of risk" of these so-called problems that "may" happen in the long-term for those with type II diabtes.

The laundry list of long-term "potential" complications, that "may" happen if one follows a low-carb diet over the long-term can be summed up as the very same list - cardiovascular disease, high blood pressure, dyslipidemia, osteoporosis, kidney failure, etc. - that those already diagnoised with type II diabetes and currently following the recommendations are doomed to given the progressive deterioritation that can be predicted, with certainty, following the current recommendations.

This new algorithm is placing a band-aid on the symptom - we know a band-aid doesn't make a cut magically disappear or go away - it covers the cut, you can no longer see the cut, but the cut is still there!

The progressive deterioritation will remain a certainty unless the underlying cause of the metabolic chaos is addressed - medicating the problem is not resolving the problem.

It is not restoring balance in the metabolism. So, while this new consensus statement is going to become gospel in the world of diabetes educators and healthcare providers, it's not doing anything to stop or reverse the train-wreck happening in the metabolism.

With an estimated one-third of the adult population in the United States already diagnoised with diabetes or pre-diabetes, isn't it time we take this seriously enough to adopt an evidence-based approach that is truly based on evidence?

As it stands, we're in the middle of an impending crisis in our health and healthcare system. The band-aid, that is throwing more drugs at the problem, is not going to solve this crisis and is not our only option.

Monday, August 14, 2006

It's been a while since I have reduced carbohydrate this much - to 20g net per day, deducting only fiber from the total.

The last time I restricted my carbohydrate this much was after a vaction with friends to Las Vegas in July 2002. At that point, I'd already lost a lot of weight following a low-carb diet and increased my carbohydrate intake as suggested along the way; I'd still not learned the importance of maintaining a relatively low level of carbohydrate intake consistently, enjoyed a few too many desserts, and returned home with a few too many pounds gained.

Solution? Start again to get back on track.

Within a week the few gained pounds were gone and I was back on track to lose the weight I needed. It was an important lesson for me in the long-term - when the goal is to lose weight and keep it off, consistency is critical. When I went on vacation in July 2002, I'd been following a low-carb diet for just nine months - it was still a "diet"; after a short abandonment from the consistency that had resulted in an effortless weight loss, I realized the dietary modification was more than just a diet, it was a long-term lifestyle. It was after that period of starting again that I really understood how important, and often times difficult, it is to maintain healthful eating in the face of an abundance of junk food.

This time not because I'd abandon eating a nutrient-rich diet each day, but because I need to focus to lose the last twenty pounds gained while pregnant with my son. I decided to do this publically to highlight to those reading that, whether you've gotten off track; gained some weight for any number of reasons; or not paid as much attention as you should to your diet, you always have an incredible option - start again!

Now I have to say, the hardest part this week has been limiting my carbohydrate intake to just 20g net per day; it means paying attention at each meal to what you're eating and making the very best choices at each meal. Success means making the commitment to just do it and following through.

When you do that, weight loss takes care of itself if you maintain your carbohydrate intake, make good choices and eat to satiety your meats, poultry, fish, etc. As I've learned, the last part - eating to satiety your meats, poultry, fish, etc. - is often the undoing of those just starting a low-carb diet. Some start this type of a dietary modification with old habits, like a serving of meat is as big as a deck of cards...they think more than that is too much; or think only skinless chicken breasts are acceptable, other parts of the chicken are too fatty; or they still hold the idea that regular salad dressing adds too many calories and reach for the fat-free instead.

The reason these habits die hard is that it's difficult to detach from the negative messages about eating animal foods and fats/oils; difficult to imagine bread is off limits for a period of time; even worrisome that you're excluding something as "healthy" as bananas.

I'll tell you what - been there, done that and can say, if you set aside your preconceived notions of a "healthy diet," and make the best choices while following a low-carb diet, you'll see success.

I did continue with the vitamin C, zinc and ecinacea even though I was feeling a bit better....this morning, I'm happy to report I'm feeling MUCH better and it seems my immune system has kicked the virus/bacteria out of my respiratory system and today I'll probably have some lingering stuffiness that will disappear as the day continues and my immune system continues to do its magic.

Yesterday, the findings were highlighted in MedPage Today with the following statement as part of the "action points" for healthcare professionals:

Explain to patients with type 2 diabetes and their families that this study shows that both an ADA diet and a low fat vegan diet can significantly improve glycemic control, reduce the risk for cardiovascular and other risk factors, and prevent or delay the need for insulin injections. Further, this study suggests that the vegan diet may produce better results than the ADA diet.It's disturbing to read such garbage, especially when you know it's targeting healthcare providers who are going to communicate this bunk to their patients!

Nowhere in the article do you read about the fact that among all participants, regardless of dietary intervention, they remained obese, with fasting blood sugars above the diabetic threshold, with HbA1C levels remaining above the ADA's 7% or lower target, and they experienced a decline in HDL levels while triglycerides remained elevated above the target of less than 100mg/dL for those with diabetes.

There is also no mention that the researchers didn't see fit to publish data showing effect of either diet on fasting insulin or post-prandial insulin; or post-prandial blood glucose. The researchers also failed to provide data separately for men and women for HDL, even though, for HDL levels, the targets are different.

To promote the vegan diet as "better" for those with diabetes is misleading as neither diet achieved the target of what is considered the critical marker for glycemic control over time - HbA1c. The target for those with diabetes is to reduce to and maintain their HbA1c at or below 7%. Anything above that level is considered poor glycemic control.

On its Medline site, the National Institutes of Health (NIH) states "If the HbA1c value is above 7%, it means your diabetes is poorly controlled."

Poorly Controlled!

Yet here we have findings where HbA1c persisted above 7% being touted as a better option for those with diabetes.

Those following the ADA diet for 22-weeks had HbA1c levels of 7.4%; those following the Vegan diet had HbA1c levels of 7.1%.

Even though both groups did have improvement from baseline, both groups remained above the level established to indicate good glycemic control after 22-weeks of compliance with both dietary interventions!

If the goal is to reduce the risk of complications from diabetes, then we must be sure we are promoting only those interventions shown to specifically make significant improvements and stop with this "hey, this is better than that" when neither are in fact helping those with diabetes reach the targets established to reduce the long-term risks from complications of poor glycemic control.

To say the Vegan diet was better is to consider less than acceptable results as better than less than acceptable results.

Neither diet acheived the 7% or less target for HbA1c!

So then, we need to know - are there any studies, of similar duration that indicate there may be a more effective dietary approach to achieving the risk marker targets for those with diabetes?

We find in the literature another dietary intervention study, of much longer length (22-months duration) that DID show significant improvements in those with diabetes; and resulted in better improvements when compared with this study in both the Vegan Group and the ADA Group.

Yes, there really is a study out there, that was longer than this one, that not only found greater improvements when followed; but achieved the ADA target of less than 7% for HbA1c!

In the study above, after the 22-weeks of dietary compliance, all participants in the Vegan Group had an average HbA1c of 7.1%; all participants in the ADA Group had an average HbA1c of 7.4%.

They achieved an HbA1c below the target of 7% when sticking with the diet.

Of particular interest is the results from those participating who originally followed the low-fat diet for the first six months of the study. After seeing the results for those following the low-carb diet they abandon the low-fat diet and started following the low-carb diet. At the 22-month mark, their HbA1c averaged 5.7%!

Oh, and did I mention the low-carb dieters (both those who followed it continuously for 22-months or jumped on it after six months) didn't have intensive counseling or support to maintain compliance.

In their presentation of this study and their actions points to healthcare professionals, MedPage Today failed the basic rules of evidence-based medicine. As I've said before, "Those with type II diabetes, those with pre-diabetes, and those at risk for developing insulin resistance which will lead to diabetes must be given all the facts so they can make a decision based on the full data available - anything less fails the standard of informed consent."

Yet, here we have the media jumping on this study comparing a Vegan diet to the ADA diet, with unimpressive results after 22-weeks. We find MedPage Today touting the Vegan diet as "better"; Medical News Today reporting "low-fat vegan diet treats type 2 diabetes more effectively than a standard diabetes diet..."; and The Australian proclaiming "a low-fat vegan diet is the most effective treatment for type 2 diabetes - better than the current recommended diet..."

What's disturbing here isn't just the lack of enthusiasm after the publication of the findings from the low-carbohydrate diet trial; it's also troubling that both journalists and medical information sites are publishing articles that are out-of-synch with the published data in this new trial and seem intent on promoting a dietary approach that was not able to bring HbA1c to 7% or less!

Add to that the problematic decline in HDL with a persistent elevation of triglycerides.

What we have here is a widespread habit of dismissing incovenient data; disregarding facts; and simply ignoring compelling findings to maintain the status quo. The numbers in the study comparing a Vegan diet to the ADA diet are accurate and reflect how the dietary interventions effected those with type II diabetes.

The correct definition of "success" - reaching established targets - however leaves little to be desired with either the vegan 0r ADA diet since neither resulted in improvement to or below targets; thus this renders the findings meanlingless as a long-term dietary appraoch to improve glycemic control to the established target of an HbA1c of 7% or less.

Just don't expect the establishment to admit it is continuing to fail patients because they won't even consider the efficacy of a low-carbohydrate diet.

Yesterday was a bit different since it seems I'm coming down with a cold. My appetite was significantly less than usual and I added some supplements in an effort to boost my immune system to fight off what might be a cold brewing:

This morning I'm feeling a bit better. Still a bit stuffy, but that "taste" in the back of the throat that comes when you know you're getting sick is almost gone....here's to the power of Vitamin C, Zinc and echinacea!

The first sentence is equally ominous, "Scientists at The Heart Research Institute in Sydney, Australia warned that a single bite of a burger or one meal high in saturated fat is enough to cause a heart attack."

The use of argumentum ad metam (an appeal to fear) begs our attention; created in this instance, as a logical fallacy, to support the dogma that dietary saturated fat is deadly - if we eat it, even just one bite of it in a foof that has saturated fat, like a burger, we risk an immediate death by heart attack.

Really, who wants to risk taking a single bite of a burger if it might cause them immediate death?

This is exactly the fear cojured up in the headline and first sentence - eat that bite and you'll die of a heart attack.

Makes you wonder how many people died eating just one bite of a burger in the study? Oh, that would be none.

So, then, how many people died eating a high fat meal that included eating a whole burger? Oh, that too would be none.

Why then the histrionics about taking a bite of a burger?

Surely someone had to keel over eating just a bite of something laden with saturated fat, no?

No

But, we must convince the population that the evil, unnessasary, artery clogging, heart damaging saturated fat must be banished from their diet...NOW!

The American Heart Association, American Diabetes Association, American Dietetics Association, and well, every leading medical/disease oriented organization and even the US government all repeatedly insist saturated fat is deadly; recommendations over the past few decades have dropped steadily as more and more "proof" is presented that consuming saturated fat will give you a heart attack.

This particular study is being promoted in the media as evidence that the cause-and-effect of saturated fat is immediate in the body and therefore it is deadly to eat in even small or moderate amounts.

You may be wondering, what exactly did the study find?

The short answer - they found that when you give a small number of subjects a slice of carrot cake and a milkshake rich with poly-unsaturated fat (75% of the total fat was PUFA; safflower oil) it had a less damaging effect in the hours following the "meal" than when the slice of carrot cake and milkshake was rich with saturated fat (89.6% of the total fat was SFA; coconut oil).

Pay no mind to the fact that:

both types of fat had acute effects that could be called "damaging" but with no real statistically significant differences. As the researchers put it, "a non-significant trend toward impairment..." Not only was it a "trend" - it was a NON-SIGNIFICANT trend, basically nothing to get your panties in a wad about;

the high-polyunsaturated fat "meal" resulted in a statistically significant rise in LDL (remember that pesky "bad" cholesterol) compared to the saturated fat "meal";

But, hey, it's the saturated fats....they're deadly. Just step away from the burger and no one will get hurt.

Facts, data or findings that go against the preconceived notions are going to be ignored. People who have made up their minds and don't want to be confused by the lack of hard data are no longer an exception these days, but accepted as "expert" as long as they continue to perpetuate the dogma that saturated fat is deadly in any and every dietary context.

These days, it is apparent that scholars, as well as journalists, have made their minds up and don't want to be confused by the facts and instead will make a massive effort to muddy the waters even more; sow confusion; and instill a fear that saturated fats are lethal - even with just one bite - in the diet of humans.

Thus, we're expected to be good little soldiers in the war against obesity and heart disease and ignore any potential defects in studies such as this.

By establishment standards, I'm not being a good little soldier here pointing out the glaring flaws with this data. I simply cannot, in good consciousness, ignore the methods used to scare the begeebers out of those reading the various headlines this week, nor the flaws in the very short study with too few subjects (that alone render it meaningless) that had confounding variables (fatty acid composition, fatty acid chain length, sugar, blood glucose, insulin) the researchers did not control for and completely failed to even mention in the findings and discussion!

The lead researcher, Dr. Stephen Nicolls was quoted in the media, "The take-home, public-health message is this: It's further evidence to support the need to aggressively reduce the amount of saturated fat consumed in the diet."

Even though the full-text of the paper was specific, "In summary, the present study raises the possibility that the differential effects of dietary fats on the anti-inflammatory potential of HDL and endothelial function may contribute to the apparent benefits of polyunsaturated over saturated diets observed in the epidemiologic literature."

Pray tell, which population can we find that observation in the literature?

It's certainly not obeserved in the French, where "[c]onsumption studies...show a high dietary fat contribution (37-38% even 40% of total energy) with over-consumption of saturated fatty acids, under-consumption of monounsaturated fat and, to a lesser extent of polyunsaturated fatty acids." That is, of course "over consumption" defined by our dogma that any level above 7-10% of calories is excessive and harmful. Ignore the fact the French live longer than we, in better health, with significantly less cardiovascular disease.

Let's just call them a "paradox."

Oh no, we better call Spain a paradox too since "[t]rends in food consumption show increases in intakes of meat, dairy products, fish, and fruit, but decreases in consumption of olive oil, sugar, and all foods rich in carbohydrates. Although fat and saturated fat intakes increased, these changes were not accompanied by an increase in CHD mortality rates." Ignore the fact they live longer than we, in better health, with significantly less cardiovascular disease and declining rates of cardiovascular disease despite increases in their consumption of saturated fat!

Gosh, even the epidemiologists concede "Between-population ecologic studies have demonstrated an association between intake of fat, specifically saturated fat and total cholesterol and coronary heart disease (CHD) mortality. However, results are inconsistent from within-population cohort studies."

So, again, where is that proof in the literature? Where's the data? Where's the evidence?

Rather than present hard data, the tactic now is to scare the daylights out of people with headlines that warn of immediate death by heart attack if they take just one bite of a burger.

Repeat the lie often enough and people hold it as truth.

Except of course by those who take the time to actually read the studies, investigate the referenced citations of support of the findings, review the design and methods in various studies, check to see if statistically significant findings synch with the abstract, figure out if the study had any statistical power, and examine if all confounding variables were controlled for.

Or those who take the time to read the analysis of those of us who do!

Yesterday was day three of my return to a low-carb diet in an effort to lose 20-pounds in the coming weeks and months. As you'll notice, my menu doesn't vary all that much on a day-to-day basis at the start. Yesterday, my menu included:

The study is due for publication in the Journal of the American College of Cardiology, August 15th. Since the data is not yet available for review, I will wait (unlike those in the media jumping up and down to vilify saturated fats) until I can read through the full-text of the paper before analyzing the results/conclusions reached.

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Dr. Mike Eades wrote about an article in the Wall Street Journal about a study showing the importance of fat for micronutrient bioavailability.

Interestingly, the lead researcher is suggests "that in addition to a well-balanced diet, it is advantageous to incorporate CLA as a dietary supplement, or to seek out new products that enrich foods such as butter, margarine and ice cream with CLA."

Folks, CLA is naturally occuring in pastured (grass-fed, not grain fed) ruminant animal meats (cows, goats, lamb, deer, etc.) as well as whole milk and milk products from those animals. "The compounds are predominantly found in dairy products such as milk, cheese and meat, and are formed by bacteria in ruminants that take linoleic acids -- fatty acids from plants -- and convert them into conjugated linoleic acids, or CLA," says Jack Vanden Heuvel, professor of molecular toxicology in Penn State's College of Agricultural Sciences and co-director of Penn State's Center of Excellence in Nutrigenomics.

Unfortunately the feedlot animals, fed a steady diet of grains to fatten them or increase milk production, that dominant the food supply in the US, is lower in CLA.

But, CLA supplements are industrial hydogenated fats, which some studies have found problematic in supplement form:

In obese men, t10c12CLA induces hyperproinsulinaemia that is related to impaired insulin sensitivity, independently of changes in insulin concentrations. These results are of clinical interest, as hyperproinsulinaemia predicts diabetes and cardiovascular disease. The use of weight-loss supplements containing this fatty acid is worrying.

In this study, researchers found that CLA supplements decreased insulin sensitivty, raised fasting plasma glucose levels, and increased the concentration of C-reactive protein, a marker of inflammation and an independent predictor of cardiovascular risk. The authors also noted evidence that manmade CLA may produce enlargement of the liver and insulin resistence.

If you want to understand the process of making supplements of CLA, here is a patent to read from one company's process: United States Patent: 5554646

SYNTHESIS OF CONJUGATED LINOLEIC ACIDS (CLA) FROM LINOLEIC ACID AND SAFFLOWER OIL Ethylene glycol (1000 g) and 500 g potassium hydroxide (KOH) are put into a 4-neck round bottom flask (5000 ml). The flask is equipped with a mechanical stirrer, a thermometer, a reflux condenser, and a nitrogen inlet. (The nitrogen introduced in first run through two oxygen traps). Nitrogen is bubbled into the ethylene glycol and KOH mixture for 20 min and the temperature is then raised to 180.degree. C. 1000 g of linoleic acid, corn oil, or safflower oil is then introduced into the flask. The mixture is heated at 180.degree. C. under an inert atmosphere for 2.5 hours. The reaction mixture is cooled to ambient conditions and 600 ml HCl is added to the mixture which is stirred for 15 min. The pH of the mixture is adjusted to pH 3. Next, 200 ml of water is added into the mixture and stirred for 5 min. The mixture is transferred into a 4 L separatory funnel and extracted three times with 500-ml portions of hexane. The aqueous layer is drained and the combined hexane solution extracted with four 250-ml portions of 5% NaCl solution. The hexane is washed 3 times with water. The hexane is transferred to a flask and the moisture in the hexane removed with anhydrous sodium sulfate (Na.sub.2 SO.sub.4). The hexane is filtered through Whatman paper into a clean 1000 ml round bottom flask and the hexane removed under vacuum with a rotoevaporator to obtain the CLA. The CLA is stored in a dark bottle under argon at -80.degree. C. until time of use.

Personally, I don't recommend the use of CLA supplements. Nature has a very simple process - ruminent eats grass/forage rich with LA and its converted to CLA. No need to make it ourselves in a process of hydrogenation. Haven't we learned our lesson yet about processing oils?